Harvard Pilgrim Health Care Medical Policy

Durable Medical Equipment STRIDESM (HMO) MEDICARE ADVANTAGE

Subject: Durable Medical Equipment

Authorization: Prior authorization is required for any single DME item with a Harvard Pilgrim StrideSM (HMO) Medicare Advantage allowable payment amount of $500 or more.

Policy and Coverage Criteria:

Harvard Pilgrim StrideSM (HMO) Medicare Advantage considers Durable Medical Equipment (DME) as reasonable and medically necessary for the treatment of the member's illness or injury, and when documentation confirms All the following indications:

• DME is reasonable and medically necessary based on the member’s condition, complexity of requested service(s), and accepted standards of clinical practice;
• DME is considered as an essential part of active treatment of the member’s medical condition, and ordered under a plan of care established and reviewed regularly by the attending physician caring for the member; and
• DME will provide therapeutic benefits, improve the functioning of a malformed body part, and/or enable the member to perform tasks that she or he would otherwise be unable to undertake due to his/her medical condition or illness;

The DME item will be used primarily in the home (but may be transported to other locations);

• DME is furnished by provider(s) with appropriate state licensure, and accreditation/certification from an appropriate accrediting organization (e.g. JCAHO, CMS).

Medicare defines durable medical equipment (DME) as equipment that:

• Can withstand repeated use
• Generally, is not useful to a person in the absence of an illness or injury
• Has an expected lifetime of at least three years

All requirements of this definition must be met before an item is considered to be DME.

Exclusions:

Harvard Pilgrim StrideSM (HMO) Medicare Advantage considers durable Medical Equipment (DME) as not medically necessary for all other indications

Summary of Changes:

Date: 1/2022
Revision: Annual review; no changes

HPHC Medical Policy Page 1 of 2 Durable Medical Equipment VC03FEB22P

Harvard Pilgrim StrideSM (HMO) policies are based on medical science and relevant information including current Medicare coverage (including National and Local Coverage Determinations), Harvard Pilgrim medical policies, and Harvard Pilgrim StrideSM (HMO) Medicare Advantage Plan materials. These policies are intended to provide benefit coverage information and guidelines specific to the Harvard Pilgrim StrideSM (HMO) Medicare Advantage Plan. Providers are responsible for reviewing the CMS Medicare Coverage Center guidance; in the event that there is a conflict between this document and the CMS Medicare Coverage Center guidance, the CMS Medicare Coverage Center guidance will control.

Policy Effective Date:

5/2020 10/17 10/12/16

Approved by Medical Policy Committee:

1/19/22

Approved by Clinical Policy Operational Committee:

10/16; 9/17; 2/20; 6/20; 2/21; 2/22

Policy Effective Date:

2/3/22

Initiated: 8/26/15

HPHC Medical Policy Page 2 of 2 Durable Medical Equipment VC03FEB22P

Providers are responsible for reviewing the CMS Medicare Coverage Center guidance; in the event that there is a conflict between this document and the CMS Medicare Coverage Center guidance, the CMS Medicare Coverage Center guidance will control.